Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

Manassé Nimpagaritse, Catherine Korachais, Georges Nsengiyumva, Jean Macq, Bruno Meessen, Manassé Nimpagaritse, Catherine Korachais, Georges Nsengiyumva, Jean Macq, Bruno Meessen

Abstract

Background: The Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level.

Methods: We carried out direct observations of curative outpatient consultations for children aged 6-59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed.

Results: A total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice.With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2-30.5%) systematically asked the question regarding 'ongoing breastfeeding'.Only 56 (38.6%)[31-46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6-34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7-22.8%] performed (systematically?) the WHZ-score.More than 50% never gave nutrition advices to any child reviewed.HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding 'ongoing breastfeeding' and to perform a 'weight examination'. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a 'weight examination'. The 'height/length' examination' was predominantly performed by female HWs and those who have 'contract with the government.

Conclusion: This study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country.

Trial registration: Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

Keywords: Burundi; Health Centre; IMCI; Implementation research; Malnutrition.

Conflict of interest statement

Competing interestsBruno Meessen contributed to the emergence of PBF as a global health policy, through technical assistance, research and knowledge management. He is the lead facilitator of the PBF Community of Practice. He holds minority shares in Blue Square, a firm developing PBF software solutions. Other authors declared no conflict of interest.

© The Author(s). 2019.

References

    1. Hug L, Sharrow D, You D. Levels & trends in child mortality: report 2017. 2017.
    1. Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. 1995. The effects of malnutrition on child mortality in developing countries. Bulletin of the World Health Organization73: 443–448.
    1. Caulfield LE, Richard SA, Black RE. 2004. Undernutrition as an underlying cause of malaria morbidity and mortality in children less than five years old. American Journal of Tropical Medicine and Hygiene71: 55–63.
    1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al. Maternal and child undernutrition study group. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371(9610):417–440. doi: 10.1016/S0140-6736(07)61693-6.
    1. Markowitz LE, Nieburg P. The burden of acute respiratory infection due to measles in developing countries and the potential impact of measles vaccine. Rev Infect Dis. 1991;13(Suppl 6):S555–S561. doi: 10.1093/clinids/13.Supplement_6.S555.
    1. Mathew JL, Patwari AK, Gupta P, Shah D, Gera T, Gogia S, et al. Acute respiratory infection and pneumonia in India: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health. India Indian Pediatrics. 2011;48(3):191–218. doi: 10.1007/s13312-011-0051-8.
    1. Thwing J, Eisele TP, Steketee RW. Protective efficacy of malaria case management and intermittent preventive treatment for preventing malaria mortality in children: a systematic review for the lives saved tool. BMC Public Health. 2011;11(Suppl 3):S14. doi: 10.1186/1471-2458-11-S3-S14.
    1. Tulloch J. Integrated approach to child health in developing countries. Lancet. 1999;354(suppl 2):SII16–SII20. doi: 10.1016/S0140-6736(99)90252-0.
    1. Gove S. For the WHO working group on guidelines for integrated Management of the Sick Child. Integrated management of childhood illness by outpatient health workers: technical basis and overview. Bull World Health Organ. 1997;75(suppl 1):7–24.
    1. Bryce J, Victora CG, Habicht JP, Vaughan JP, Black RE. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. Am J Public Health. 2004;94(3):406–415. doi: 10.2105/AJPH.94.3.406.
    1. Gera T, Shah D, Garner P, Richardson M, Sachdev HS. Integrated management of childhood illness (IMCI) strategy for children under five. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD010123. 10.1002/14651858.CD010123.pub2.
    1. World Bank Burundi 2018.
    1. Ministère de la Santé Publique et de la Lutte contre le SIDA, 2012. Profil des ressources humaines en Santé au Burundi.
    1. Ministère de la Santé Publique et de la Lutte contre le SIDA, 2004. Politique Nationale de la Santé 2005–2015.
    1. Ministère à la Présidence chargé de la Bonne Gouvernance et du Plan [Burundi] (MPBGP), Ministère de la Santé Publique et de la Lutte contre le Sida [Burundi] (MSPLS), Institut de Statistiques et d’Études Économiques du Burundi (ISTEEBU), et ICF. 2017. Troisième Enquête Démographique et de Santé . Bujumbura, Burundi : ISTEEBU, MSPLS, et ICF.
    1. Nimpagaritse M, Korachais C, Roberfroid D, Kolsteren P. Zine Eddine El Idrissi MD. Meessen B Measuring and understanding the effects of a performance based financing Scheme applied to nutrition services in Burundi – a mixed method research design International Journal for Equity in Health. 2016;15:93. doi: 10.1186/s12939-016-0382-0.
    1. Gouws E. Bryce Jennifer, Pariyo G, Schellenberg Joanna Armstrong, Amaral J. Habicht JP Measuring the quality of child health care at first-level facilities Social Science & Medicine. 2005;61:613–625.
    1. WHO, 2014. Integrated Management of Childhood Illness: Chart Booklet,
    1. MSPLS . Protocole national de prise en charge intégrée de la malnutrition aigüe globale. 2010.
    1. Arifeen SE, Bryce J, Gouws E, Baqui AH, Black RE, Hogue DM, et al. Quality of care for under-fives in first-level health facilities in one district of Bangladesh. Bull World Health Organ. 2005;83(4):260–267.
    1. Rowe AK, Onikpo F, Lama M, Cokou F, Deming MS. Management of childhood illness at health facilities in Benin: problems and their causes. Am J Public Health. 2001;91:1625–1635. doi: 10.2105/AJPH.91.10.1625.
    1. Lunze K, Biemba G, Lawrence JJ, MacLeod WB, Yeboah-Antwi K, Musokotwane K, Ajayi T, Mutembo S, Puta C, Earle D, Steketeei R, Hamer DH. Clinical management of children with fever: a cross-sectional study of quality of care in rural Zambia. Bull World Health Organ. 2017;95:333–342. doi: 10.2471/BLT.16.170092.
    1. Horwood C, Vermaak K, Rollins N, Haskins L, Nkosi P, et al. An evaluation of the quality of IMCI assessments among IMCI trained health Workers in South Africa. PLoS One. 2009;4(6):e5937. doi: 10.1371/journal.pone.0005937.
    1. Leslie HH, Malata A, Ndiaye Y, et al. Effective coverage of primary care services in eight high-mortality countries. BMJ Glob Health. 2017;2:e000424. doi: 10.1136/bmjgh-2017-000424.
    1. Arifeen SE, Blum LS, Hoque DME, Chowdhury EK, Khan R, Black RE, Victora CG, Bryce J. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet. 2004;364:1595–1602. doi: 10.1016/S0140-6736(04)17312-1.
    1. Pariyo GW, Gouws E, Bryce J, Burnham G. Improving facility-based care for sick children in Uganda: training is not enough. Health Policy Plan. 2005;20(suppl 1):i58–i68. doi: 10.1093/heapol/czi051.
    1. Arifeen S E, Hoque DME, Akter T, Rahman M, Hoque ME, Begum K, Chowdhury EK, Khan R, Blum LS, Ahmed S, Hossain MA, Siddik A, Begum N, Rahman QS, Haque TM, Billah Sk M, Islam M, Rumi RA, Law E, Al-Helal Z A M, Baqui AH, Schellenberg J, Adam T, Moulton L H, Habicht JP, Scherpbier RW, Victora CG, Bryce J, Black RE. Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial. Lancet 2009; 374: 393–403.
    1. Oladele, EA, L Ormond, O Adeyemi, D Patrick, F Okoh, OB Oresanya, and JJ. Valadez. 2012. “Tracking the quality of Care for Sick Children Using lot Quality Assurance Sampling: targeting improvements of health Services in Jigawa, Nigeria.” PLoS One 7 (9).
    1. Valadez JJ, Brown LD, Vargas WV, Morley D. Using lot quality assurance sampling to assess measurements for growth monitoring in a developing Country’s primary health care system. Int J Epidemiol. 1996;25(2):381–387. doi: 10.1093/ije/25.2.381.
    1. Black RE, Allen LH, Bhutta ZA, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; Lancet 2003; 371, No. 9608, p243–p260.
    1. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. Lancet 2000; 355: 451–455.
    1. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio child survival study group. How many child deaths can we prevent this year? Lancet. 2003;362:65–71. doi: 10.1016/S0140-6736(03)13811-1.
    1. Boschi-Pinto C, Labadie G, Dilip TR, et al. Global implementation survey of integrated Management of Childhood Illness (IMCI): twenty years on. BMJ Open. 2018;8:e019079. doi: 10.1136/bmjopen-2017-019079.
    1. Tanya Doherty, Nhan Tran, David Sanders, Sarah L Dalglish, David Hipgrave, Kumanan Rasanathan, Thiagarajan Sundararaman, Rajani Ved, Elizabeth Mason. Role of district health management teams in child health strategies. BMJ 2018;362:k2823.
    1. Manary, M. & Brewster, D., 2000. Intensive nursing of children with kwashiorkor in Malawi. Acta Paediatr, 89, p.203±7.
    1. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452–477. doi: 10.1016/S0140-6736(13)60996-4.
    1. Singh K, et al. Management of Children with severe acute malnutrition: experience of nutrition rehabilitation centers in Uttar Pradesh, India. Indian Paediatrics. 2014;51:21–25. doi: 10.1007/s13312-014-0328-9.
    1. Alexander K Rowe, Guilhem Labadie, Debra Jackson, Claudia Vivas-Torrealba, Jonathon Simon. Improving health worker performance: an ongoing challenge for meeting the sustainable development goals. BMJ 2018;362:k2813.
    1. Korachais C, de Polnay K, Nkurunziza S, Nimpagaritse M, Kolsteren P, Meessen B. FBP Nutrition au Burundi : Rapport des enquêtes de référence au niveau des centres de santé et des ménages. Belgique: Institut de Médecine Tropicale d’Anvers; 2015.
    1. Baiden F, Owusu-Agyei S, Bawah J, Bruce J, Tivura M, et al. An evaluation of the clinical assessments of under-five febrile children presenting to primary health facilities in rural Ghana. PLoS One. 2011;6(12):e28944. doi: 10.1371/journal.pone.0028944.
    1. Bishai D, Mirchandani G, Pariyo G, Burnham G, Black R. The cost of quality improvements due to integrated management of childhood illness (IMCI) in Uganda. Health Econ. 2008;17:5–19. doi: 10.1002/hec.1231.
    1. Rowe AK, de Leo’n GF, Mihigo J, Santelli AC, Miller NP, et al. Quality of malaria case management at outpatient health facilities in Angola. Malar J. 2009;8:275.
    1. Huicho L, Scherpbier RW, Nkowane AM, Victora CG. Multi-country evaluation of IMCI study group. How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study. Lancet. 2008;372:910–916. doi: 10.1016/S0140-6736(08)61401-4.
    1. Bonfrer I, Soeters R, Van de Poel E, Basenya O, Gashubije L, van de Looij F, van Doorslaer E. Introduction of performance-based financing in Burundi was associated with improvements in care and quality. Health Aff. 2014;33(12):2179–2187. doi: 10.1377/hlthaff.2014.0081.
    1. Fritsche G. and Peabody J. Methods to improve quality performance at scale in lower- and middle-income countries. Journal of Global Healt. December 2018 • Vol. 8 No. 2. 10.7189/jogh.08.021002

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